Braz 254 Dent J (2005) 16(3): 254-258

C.R.A. Valois and E.D. Costa-Júnior

ISSN 0103-6440

Periapical Cyst Repair After Nonsurgical Endodontic Therapy - Case Report
Caroline R.A. VALOIS Edson Dias COSTA-JÚNIOR

Faculty of Health Sciences, Department of Dentistry, University of Brasília (UnB), Brasília, DF, Brazil

This article presents the procedures that must be considered for periapical cyst repair after nonsurgical endodontic treatment. The case of a periapical cyst associated to the left maxillary lateral incisor is reported. Nonsurgical root canal therapy was performed and lesion healing was confirmed radiographically after 24 months. Differential diagnosis, endodontic infection control, apical foramen enlargement and filling of the cystic cavity with a calcium hydroxide paste were important procedures for case resolution. Key Words: endodontic therapy, periapical cyst, periapical pathosis.

INTRODUCTION
The periapical cyst is originated from the epithelium in a granuloma and is frequently associated to an inflammatory response of the organism against a long-term local aggression due to an endodontic infection. This condition is clinically asymptomatic but can result in a slow-growth tumefaction in the affected region. Radiographically, the classic description of the lesion is a round or oval, well-circumscribed radiolucent image involving the apex of the infected tooth (1). Although it has been demonstrated that this pathologic entity can represent 40 to 50% of all apical lesions (2), it is not yet well-established in the literature whether its treatment should be surgical or non-surgical. Some authors support that if the endodontic infection is eliminated, the immune system is able to promote lesion repair, while other believe that surgical intervention is invariably necessary (1-5). In this article, a case of periapical cyst healing after nonsurgical endodontic treatment is reported.

CASE REPORT
A 42 year-old female patient was referred to our clinic for endodontic treatment of the left maxillary

lateral incisor. Intraoral clinical examination revealed that the lateral incisor had esthetic restorations on the mesial, distal and lingual surfaces. The buccal mucosa presented normal color and appearance. There was no gingival or extraoral swelling but a volumetric increase in the palate was observed. The patient denied spontaneous pain but reported painful symptomatolgy upon percussion. The radiographic examination showed the presence of external periapical resorption of approximately 1 mm length and a radiolucent lesion (15 x 10 mm) surrounded by a tenuous radiopaque line adjacent to the apex of tooth 22. Pulpal necrosis was confirmed by cold sensitivity testing done with EndoFrost cold spray (Roeko, Langenau, Germany). After crown opening, a mucous and transparent exudate drained through the radicular canal. A sample of this fluid was collected for cytological examination. The canal was instrumented at 1 mm from the apical foramen according to the crown-down technique. The memory instrument was a size 60 K-file (Maillefer Instruments SA, Ballaigues, Switzerland). The canal was irrigated with HCT20, an irrigating solution composed of calcium hydroxide, tergentol and distilled water (6), and filled with a paste prepared with 9 parts of calcium hydroxide and 1 part of zinc oxide in an

Correspondence: Dr. Edson D. Costa Jr., Faculdade de Odontologia, Universidade de Brasília (UnB), Campus Universitário, Asa Norte, 70910-900 Brasília, DF, Brasil. Tel: +55-61-307-2632. e-mail: cravalois@uol.com.br/edsondias@opendf.com.br

Braz Dent J 16(3) 2005

purulent and hemorrhagic exudate flowed through the root canal. periapical radiographs showed a remarkable decrease of the radiolucency of the lesion and partial resorption of the calcium hydroxide paste (Fig. France) and the access cavity was closed with a rapid-setting zinc oxide and eugenol based cement (Pulpo-san. DISCUSSION It is known that a pulpal infection originates and perpetuates periapical pathologic alterations. and refusal to undergo surgical procedures. Radiographic evidence of lesion healing was observed at the 24-month follow-up. Therefore. Brazil) and Sealer 26 cement (Dentsply Ind. Parendodontic surgeries may have direct procedural consequences that make nonsurgical endodontic treatment preferable over them in cases of periapical cyst. She agreed to sign an informed consent form for nonsurgical root canal therapy and documentation of her case. All procedures were carried out under absolute isolation. The calcium hydroxide paste was reapplied into the canal and intentionally taken to the periapical region using a size 30 K-file as described above. Correct planning of the intervention in cases of periapical cyst is of paramount importance for a successful therapy. SS White. 4). Nevertheless. the way that the endodontic treatment is conducted should be discussed as well. Ltda. fistula. Therefore. In addition. Therefore. After fourteen months of treatment. At this moment.5). inferior alveolar nerve and/ or artery. especially pediatric patients (4.10). monthly appointments were scheduled. The exfoliating cytology of the lesion’s fluid was compatible with periapical cyst. nasal cavity and the maxillary sinus. Septodont. Com. One month after the beginning of the treatment. obturated with gutta-percha cones (Dentsply Ind. 2). Several studies have shown the difficulty to distinguish radiographically these pathological entities (9.Periapical cyst repair 255 aqueous vehicle (HCT20). and then every 12 months during the following 3 years (Fig. postoperative pain or discomfort. possibility of damaging anatomic structures. such as the mental foramen. Brazil). RJ. the radiographic examination showed that practically all calcium hydroxide paste extruded into the periapical lesion had been resorbed. production of anatomic defects or scars. During the first month. The provisional restoration was removed and the canal was irrigated with HCT20 and filled with intracanal medication. Petrópolis. in the absence of aggressive agents. Biochemical procedures have also been described Braz Dent J 16(3) 2005 . using a lentulo drill. A size 30 K-file (Maillefer Instruments SA) was introduced 3 mm beyond the radiographic apex (Fig. pre-mixed temporary filling material (Cimpat. renewal of intracanal medication was associated to increase of sensitivity to percussion and palate tumefaction. Among the events that might be associated to periapical surgical interventions are loss of bone support. placement of intracanal dressing beyond the tooth apex was repeated. The foremost step is to establish a differential diagnosis between periapical cyst and periapical granuloma. the elimination of harmful agents from the root canal system creates a propitious environment for repair of a cystic lesion (3. at the subsequent visits. the patient returned every week for control and. RJ. A fistula developed and persisted during four days. During the following three months of treatment. but this time greater paste volume was used to completely fill the cystic cavity (Fig. Rio de Janeiro. Ltda) using the lateral condensation technique. has also been discussed in the literature (8). tooth conditions and treatment options. possibility of damaging blood vessels and nerves irrigating and innervating teeth adjacent to the lesion. the immune system has mechanisms to promote the repair of tissues and structures affected by pathologic processes (3). it was observed absence of sensitivity to percussion. there was no longer need to take the intracanal medication to the cystic cavity by advancing the file 3 mm beyond the apical foramen. tumefaction and exudate drainage through the canal. All procedures were carried out under absolute isolation. The intracanal medication was renewed at each visit. Canal entrance was sealed with a non-eugenol. Saint Maur. the fact that these findings are associated to other etiological factors. Studies have reported that periapical cysts are refractory to non-surgical endodontic therapy (7.5).8). 3). Furthermore. The root canal was chemomechanically prepared. 1). Com. The patient returned for clinical and radiographic controls every 6 months during the first 2 years. after that. At the fifth month of follow-up. such as extraradicular infection. A definitive restoration was then placed. The patient returned for a second visit and was informed about the diagnosis. an abundant serum. presence of foreign bodies and cholesterol crystals.

D.256 C.A. Note a remarkable decrease of the lesion radiolucency with partial resorption of the paste.R. Note complete healing of the periradicular cyst and resorption of the paste. Valois and E. Figure. Braz Dent J 16(3) 2005 . Radiograph taken 5 years after completion of the nonsurgical endodontic therapy. Radiograph taken 1 month after the beginning of the nonsurgical root canal therapy. Note the cystic cavity completely filled with the calcium hydroxide-based intracanal medication. Radiograph taken 14 months after the beginning of the nonsurgical endodontic therapy. Costa-Júnior Figure 1. Figure 2. Note the intentional placement of an endodontic file beyond the apex into the cystic cavity. Figure 3. Radiograph showing a periradicular cyst associated to the left maxillary lateral incisor.

15). Gutmann JL.19:315-318. Biological perspectives on the non-surgical endodontic management of perirradicular pathosis.70:333-340. Endodontic infection control is another crucial point to be addressed while planning the intervention. this will produce a transitory acute inflammation and destruction of the protective epithelial layer of the cyst. Cistos da região bucomaxilofacial. Nonsurgical resolution of radicular cysts. in the case hereby presented. Del Rio CE.66:365-371. Sundqvist G. the patient was evaluated biannually and then every 12 months up to 5 years of follow-up. Overextension of calcium hydroxide paste into cystic lesions. Differential diagnosis. Braz Dent J 16(3) 2005 .78:241-250. root canal instrumentation must be done slightly beyond the apical foramen.27:154-162. 3th ed. Almeida D. apical foramen enlargement and filling of the cystic cavity with a calcium hydroxide paste were proved important procedures for successful nonsurgical endodontic treatment of periapical cysts.27:6-10. Maalouf EM. Após o tratamento endodôntico não-cirúrgico. 3 . Birn H. controle da infecção endodôntica.600 cases. RESUMO O objetivo do presente estudo foi apresentar os procedimentos a serem considerados para o tratamento endodôntico não-cirúrgico de cistos periapicais. According to the author. failed endodontic treatments and periapical scars.13). Incidence of perirradicular pathoses in endodontic treatment failures. Calcium hydroxide irrigants and dressings were selected because they reportedly provide excellent clinical and laboratorial results (6. patency and elargement of the canals in case of necrotic teeth with periapical lesions will help eliminating microorganisms from the apical foramen. Diagnóstico diferencial. Int Endod J 1994.16). Bhaskar SN. 6 . Scand J Dent Res 1970.12. Bhaskar (2) suggested that. Figdor D. allowing conjunctive tissue invagination to the lesion (12. A dentist’s dilemma: nonsurgical endodontic therapy or periapical surgery for teeth with apparent pulpal pathosis and an associated periapical radiolucent lesion. The criteria used to establish the most adequate moment for obturation of the root canal are associated with absence of spontaneous pain. Moreover. during the endodontic therapy of teeth associated with periapical cysts. Although there is no scientific-based evidence that support this assumption. Sjögren U. which can affect the clastic activity. Calcium hydroxide was associated to an aqueous vehicle to allow rapid release of Ca++ and OH. In the case described in this paper. Persistent periapical radiolucencies of root-filled human teeth. alargamento do forame apical e preenchimento da cavidade cística com pasta de hidróxido de cálcio foram procedimentos relevantes para a resolução do caso. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1988. the professional should associate debridment using endodontic files with efficient irrigating solution and intracanal medication. J Endod 1993. Spangberg LS. The benefits of this procedure include anti-inflammatory action through hygroscopic properties forming calcium proteinate bridges and inhibiting phospholipase. 1999. a two-year period has been considered a reasonable interval (17).14. exudate and edema. Um caso de cisto periapical associado ao incisivo lateral superior esquerdo é relatado. In the case reported in this article.87:617-627. Winther JE. REFERENCES 1 . Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1990. exfoliating cytology was the chosen method to examine the lesion’s fluid because it has a simplified technique.Periapical cyst repair 257 for differencial diagnosis (4. 9 . Morse DR.13. Low surface tension calcium hydroxide solution is an effective antiseptic. For elimination or maximum reduction of microorganisms in the root canal system. thus reducing the inflammatory process. antibacterial effect and the destruction of the cystic epithelium. Barbosa SV. Nair PNR. Periapical granulomas and cysts. as performed in the case reported. neutralization of acidic products such as hidrolases. São Paulo: Editora Santos. which has better resolution. 5 . Moreover. endodontic infection control. activation of the alkaline phosphatase. and the beginning of radiographic regression of the lesion. An investigation of 1. sensitivity to percussion. 8 . 7 . Regarding the time required for considering the therapy successful. Shear M.34:458-468. Nonsurgical management of periapical lesions: a prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999. 2 . o reparo da lesão foi observado radiograficamente em 24 meses. Bhambhani SM. converting it into a granulated tissue. Int Endod J 1994. Nobuhara WK. has been previously described (12. Zinc oxide was added to the paste to allow better visualization of the medication within the canal and the cystic cavity. Mortensen H. it could also facilitate cyst resolution through the relief of the intra-cystic pressure (1). thus preventing the inflammatory process to perpetuate. instrumentation beyond the apical foramen was carried out because it would help eliminating microorganisms from the apical area. Oral Surg 1972.11). Shah N. 4 .

Sahli CC. Holland R. 11. Tratamento não cirúrgico de dentes com lesões perirradiculares.a reappraisal of criteria.46:39-46. Seltzer S. Nery MJ. An evaluation of radiographic and histopathological findings in periapical lesions. Schacterle GR. Sem BH.35:249-264. Endod Dent Traumatol 1996. Rev Bras Odont 1989. J Marmara Univ Dent Fac 1990. Patnik JW. Otoboni Filho JA. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997. Mello W.32:361-369. JF. 2004 Braz Dent J 16(3) 2005 . Endodontic success . Electrophoretic differentiation of radicular cysts and granulomas. Energin K.258 C.84:683-687.12:215-221. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1973. 14. 12.22:780-802.R. Accepted June 27.7:45-51. Çaliskan MK. Valois and E. Costa-Júnior 10.D. 13. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1966. Int Endod J 1999. Lopes HP. Siqueira Jr. Morse DR. L’hydroxide de calcium dans le traitment endodontique des grandes lesions periapicales. Rev Fran D’Endodoncia 1998. Endodontic treatment of teeth with apical periodontitis using calcium hydroxide: a long-term study. Türkün M. Souza V. 17. Mechanisms of antimicrobial activity of calcium hydroxide: a critical review. Bender IB. Soltanoff W. Kizil Z. Çaliskan MK. 15. 16.A. Periapical repair and apical closure of a pulpless tooth using calcium hydroxide.1:16-23. Bernabe PFE.

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